This is an Application for a single Life, Term Life Insurance Policy. Please fill out the application form below. We will email you your quotation along with instructions of the application process and any additional forms that are required. Please complete the below form with all of your details and when complete, click on the submit button. All fields are required. Put N/A (Not Applicable) if the questions do not apply.

First Name:

Initials:

Last Name:

Address:

Postcode:

Cell or Home Phone: (We need to call you to confirm your submission, Please put in a # that is accessible)

Email:

Age:

DOB (dd/mmm/yyyy): i.e (16/Jan/1968)

Are you in Good Health?

Yes No

Have you Smoked in the last 12 months?

Yes No

Gender:

Male Female

Language:

English French

Are you a resident for Income Tax Purposes?

Yes No

What is your Citizenship?

Coverage Required:

Term 10 Term 20 Term 30

Coverage Amount Required? (minimum is $100,000)

$

Occupation

Employer

How long with employer

Type Of Business

Annual Income

$

Net Worth

$

Main Beneficiary

Has any Application, including any request to reactivate / reinstate any life insurance, Critical Illness, Long term Care, or Disability Insurance ever been declined, rated, postponed, cancelled, recinded or modified in any way?

Yes No

Do you have any other Life Insurance with any other company?

Yes No

If yes... What company?

Is this Insurance you are applying for intended to replace another Insurance companies Policy?

Yes No

Have you applied to another Life insurance Company in the last 6 months or do you have another application pending?

Yes No

If yes... What company?

Have you within the last 5 years flown as a pilot, Student pilot, crew member or do you intend to do so?

Yes No

Have you in the last 5 years participated in Motor Vehicle racing, Motor Boat racing, Scuba Diving, Skin Diving, Sky Diving, Hand Gliding, Ultra Light Flying, Hot Air Ballooning, Mountaineering, Heli Skiing, or any other similar sport or avocation?

Yes No

If yes... What avocation? (We will send you a suplimentary questionnaire)

Have you travelled, resided or worked outside North America in the last 12 Months or do you intend to do so in the next 12 months?

Yes No

If yes... Please include countries visited, dates and length of time abroad

Have you had more than TWO moving violations in the past 3 years?

Yes No

If yes... Please give details

Have you had a license suspension, DUI or reckless drivin conviction in the last 5 years?

Yes No

If yes... Please give details

Have you had a license suspension, DUI or reckless drivin conviction in the last 10 years?

Yes No

If yes... Please give details

Have you been charged or convicted of a criminal offence?

Yes No

Have you declared Corporate or Personal Bankruptcy in the last 3 years that has not been discharged?